Non-adherence to tuberculosis contact screening and its associated factors in Kuching, Sarawak: A cross-sectional study

Abstract Introduction: Tuberculosis (TB) contacts in Malaysia undergo follow-up screening to reduce their risk of active or latent TB. However, adherence to this screening is low. Limited studies have explored the factors contributing to non-adherence to follow-up screening. This study aimed to determine the non-adherence rate and reasons in a government health clinic. Methods: Participants were TB contacts due for their 2nd contact screening (including those who attended their first contact screening at Petra Jaya Health Clinic from November 2018 to March 2019), were aged at least 18 years and were able to understand English or Malay. Data were collected during the second contact screening from August 2019 to January 2020. Results: A total of 383 TB contacts were included. Of them, 56.6% (n=217) were aged 20–39 years, and the sex distribution was equal (men: 44.1%, n=169). The majority were non-household contacts (82.2%, n=315). The rate of non-adherence to follow-up screening was 19.1% (n=73). Approximately 52.1% (n=36) reported forgetting their scheduled appointment date as the primary reason for non-adherence. The influencing factors included employment and ethnicity. Only 39.1% (n=27) were aware of their risk for active TB, while 49.5% (n=189) were unsure whether TB can be cured with proper treatment. Conclusion: The findings highlight the need to improve the reminder system for TB contacts. Although direct association between knowledge and adherence could not be established, the low percentage of correct answers to most basic knowledge questions associated with TB indicates a need to improve health education for TB contacts.


Introduction
Tuberculosis (TB) remains a disease of public health importance in Malaysia.It is one of the top 10 causes of death worldwide and the leading cause of death from a single infectious agent, Mycobacterium tuberculosis, which is spread when people who are infected with TB expel bacteria into the air.TB typically a ects the lungs (pulmonary TB) but can also a ect other sites (extrapulmonary TB).Geographically, most TB cases in 2018 were recorded in the WHO regions of South-East Asia (44%). 1 E ective contact tracing and investigations are important for successful TB control.TB contacts include individuals who live in the same household or share the same air space with the index patient for a reasonable duration before the index patient receives TB treatment.However, the minimum physical distance or exposure duration has not been well established. 2 95 studies conducted across low-and middle-income settings, the prevalence of active and latent TB was 3.1% and 51.5%, respectively, among all TB contacts screened.
e incidence was the greatest in the rst 5 years after exposure.In 108 studies performed across high-income settings, the prevalence was 1.4% and 28.1%, respectively. 3 contact screening in Malaysia is conducted at designated major government health clinics.In Sarawak, TB contacts are seen at 8-month intervals up to 2 years after the initial visit.Adherence to TB contact follow-up screening in Sarawak is poor, but no data have been published thus far.In Malaysia, limited studies have explored the factors contributing to nonadherence to follow-up screening in primary care settings. 4,5refore, this study aimed to determine the rate and associated factors of non-adherence to TB contact follow-up screening in a government health clinic in Sarawak, East Malaysia.

Methods
A cross-sectional design was adopted.Participants were TB contacts who were due for their 2nd contact screening at Petra Jaya Health Clinic in the city of Kuching, the capital of Sarawak, East Malaysia.is site was chosen, as it uses an electronic TB contact data registration system.
In Sarawak, there is a slight variation in the follow-up interval and duration for TB contact screening.Malaysia's national guideline suggests screening at the 3rd, 9th and 18th months after the initial clinic visit. 2 However, in Sarawak, the screening interval is set at 8 months after the initial clinic visit, for a total duration of 24 months. 6s variation is tailored to better suit Sarawak's geographic and logistical complexities.
Chest radiography is performed at each clinic visit, with an additional Mantoux test at the initial visit.Appointments for the subsequent 8-month screenings are written in an appointment slip given to patient by the nurse or medical assistant in charge.If patients do not turn up for their subsequent scheduled visits, the sta would rst attempt to contact them (before notifying to relevant Health Inspectors).
is is part of the clinical care practice that aims to re-engage TB contacts into the clinical care process.
In this study, TB contacts who were due for their 2nd TB contact screening (either those who adhered to their appointment dates [turned up to the clinic on their scheduled date] or those who did not [defaulted their 2nd scheduled TB contact screening date by 2 weeks or more, only turning up to the clinic after a phone call reminder by the clinic sta ]), were aged 18 years and above and were able to understand English or Malay were included.Conversely, TB contacts who did not turn up for their 2nd TB contact screening (despite 3 or more attempts of phone call reminders by the clinic sta over 1 week), were transferred out of Kuching district during data collection, were illiterate in English or Malay and were uncontactable through a phone call were excluded.
e details of eligible TB contacts were obtained from the clinic's existing electronic records (Microsoft Access).A universal sampling method was used.Upon arrival of TB contacts for their 2nd screening appointment at the TB clinic, the responsible sta noti ed one of our study team members.Our team then provided TB contacts with a participant information sheet and an informed consent form, along with detailed explanations.Upon providing consent, TB contacts received a structured and pre-tested self-administered questionnaire in their preferred language (English or Malay).
For non-adherent TB contacts (defaulted their 2nd scheduled TB contact screening date by 2 weeks or more), the clinic sta contacted them through a phone call to reschedule the appointment.When they showed up for the rescheduled appointment and agreed to participate in this study, they were then given a similar questionnaire (with an additional section on the reasons for non-adherence in their preferred language -English or Malay).
e study population comprised two groups: those who adhered to their 2nd contact screening and those who did not (Figure 1).

ORIGINAL ARTICLE
Malays Fam Physician 2024;19:28 3 Extracted data of TB contacts who were due for their 2 nd TB contact screening (n=577) • Participant information sheet and informed consent form given by the researchers  Sample size e minimum sample size required was 323, calculated using the OpenEpi software based on a P-value of 0.05 and study power of 95%, with an assumed prevalence of non-adherence of 68%. 7e sample size was increased to 380 to cover for a 15% non-adherence rate.

Questionnaire
Our questionnaire consisted of 3 main sections.
e 1st section collected data on participants' sociodemographic characteristics.e 2nd section, partly adapted and modi ed from a tool used in a study in Vietnam, 8 evaluated the reasons for non-adherence.Respondents were TB contacts who did not adhere to their scheduled screening date.
ey had to select a response for each of the 16 statements.e 3rd section assessed TB knowledge.e 19 statements in this section were partly adapted and modi ed from an instrument used in a study conducted in South Africa. 7Respondents were both TB contacts who adhered and did not adhere to TB contact screening.eir TB knowledge was evaluated, speci cally in terms of the causative factors, mode of transmission, aetiology, risk factors and at-risk groups, common symptoms and treatment.

Validation and pilot study
Approval was obtained from the authors of the 2 previous studies from which our questionnaire was adapted and modi ed. 7,8 questionnaire was translated into Malay by 2 bilingual experts.Back translation from the translated Malay version to the original English version was conducted by 2 native Malay speakers pro cient in English.e questionnaire items were reviewed for their content and face validities.Content validation was performed by an expert panel, comprising a physician from the respiratory unit of Sarawak General Hospital Kuching, a family medicine specialist from University Malaysia Sarawak and a medical o cer from Tuberculosis Control Programme Kuching.Further content validation was conducted by a biostatistician from the Clinical Research Centre, Sarawak General Hospital.e questionnaires (in both English and Malay) were then provided to 15 TB contacts to ensure that the phrasing, terminology, layout and time taken to complete the questionnaires were clear, comprehensible and appropriate to our target population.All respondents understood the questionnaire items and provided appropriate feedback.Terminologies were understood.No reliability analysis was performed (e.g.test-retest validity) given the di culty to get the same patient cohort to come back to recomplete the questionnaires, mostly stating reasons of time constraints.

Data analysis
Data were analysed using IBM SPSS Statistics version 22 (IBM, Armonk, NY).Categorical data including the patient demographic characteristics, factors for non-adherence and knowledge responses were analysed using descriptive statistics (frequencies and percentages).e association between the patient demographic characteristics and adherence and between the knowledge responses and adherence was determined using the chi-square test.P<0.05 was considered statistically signi cant.

Ethical considerations
For patient con dentiality, study numbers were used in the data collection forms instead of patient names.Hard copies of the collected data were stored manually in a locked cabinet, only accessible to the research team members.

Results
Among 450 TB contacts eligible for our study, 383 participated, and 67 were excluded, yielding a response rate of 85%.e reasons for non-response were mainly refusal to be interviewed, time constraints and work commitments at the time of visit.

Reasons for non-adherence
Of the 73 non-adherent TB contacts, 69 responded to the questionnaire section regarding the reasons for non-adherence.Among them, 52.1% (n=36) cited forgetting their scheduled appointment date as a factor for non-adherence.Approximately 39.1% (n=27) were aware of their risk for active TB.For the other reasons, most responded being unsure (Table 2).

Association between TB knowledge and follow-up adherence
Both groups correctly described the aetiology of TB.Approximately 88.2% (n=262) and 71.8% (n=51) of the participants who adhered and did not, correctly answered that TB is caused by a bacterial infection, respectively.is association was statistically signi cant (χ 2 =12.101,P=0.001).Approximately 78.9% (n=195) of the participants who adhered and 51.9% (n=27) of those who did not, incorrectly answered that TB is caused by living in an unhygienic environment.is association was also highly signi cant (χ 2 =16.407,P<0.001) (Table 4).

Demographic characteristics in uencing adherence
Our study found that 19.1% of the TB contacts did not adhere to their 2nd TB contact screening appointment date.A similar rate of non-adherence was observed in a study in Vietnam, where 13% (n=109) of TB contacts did not adhere to followup.e study reported similar participant demographics. 8A study conducted in South Africa 7 that male sex and advancing age were signi cantly associated with nonadherence.However, that study focused only on household contacts who did not adhere to follow-up screening and reported a non-adherence rate of 52.9%.Similarly, in Ethiopia, 9 the non-adherence rate was reported as 66.7%, which is higher than that in our study.However, the contact screening adherence in that study was signi cantly associated with religion, family income, relationship with contact and family support.

Factors associated with non-adherence
is study identi ed that the reason for non-adherence was mainly forgetting their appointment date (52.1%, n=36) given the long 8-month intervals of follow-up from the initial TB contact screening.
Similarly, in Vietnam, 8 70% (n=73) of participants who did not adhere to followup explained that they initially forgot their scheduled appointment.Meanwhile, in South Africa, 7 44.4% (n=20) of contacts reported di culties to get time o other duties.is factor was not a selected response for our study participants.

TB knowledge and non-adherence
For the aetiology of TB, most TB contacts from both groups correctly responded that TB is caused by a bacterial infection.A correct response rate of 88.2% (n=262) and 71.8% (n=51) was obtained from those who adhered and who did not, respectively.is nding could be due to the participants' reasonably good educational level.Our ndings are in line with those in a Vietnam study 8 that found 68% (n=126) and 55% (n=56) of those who adhered and did not adhere to follow-up, respectively, correctly describing TB aetiology.In South Africa, 7 87.3% (n=124) of TB contacts also correctly described TB aetiology.][12] Most participants were aware of TB symptoms regardless of their adherence to follow-up.Speci cally, both groups demonstrated high levels of recognition for prolonged cough lasting more than 2 weeks, unintentional weight loss and haemoptysis.Our ndings are similar to those of a study performed in Sabah, East Malaysia. 5r the transmission mode, 78.9% (n=195) and 51.9% (n=27) of the TB contacts who adhered and did not adhere, respectively, incorrectly believed that TB is caused by living in an unhygienic environment.is nding could be due to the perception that an unhygienic environment is associated with bacterial growth, indicating a lack of public awareness on the transmission mode of TB, which is airborne.A study in Vietnam 8 showed similar responses in 75% (n=139) and 83% (n=85) of contacts who adhered and did not adhere to follow-up, respectively.Indeed, overcrowding, unhealthy lifestyle, residence in close quarters with poor ventilation, poor nutrition and neglected hygiene among patients with TB are the main contributors for ongoing TB transmission, although an unhygienic environment alone does not directly contribute to it.e participants' understanding of what groups are at risk for TB varied.Notably, nearly half of our participants (49.1%, n=187) failed to recognise DM, a prevalent non-communicable disease in our population, as an important risk factor.is nding is concerning, as there is a two-to-four-fold higher risk of active TB in individuals with DM, and up to 30% of individuals with TB are likely to have DM. 13 for TB treatment, 51.1% (n=196) of the participants responded incorrectly or were unsure whether herbal or traditional medication can cure TB. is nding suggests that the Malay community still has local traditional in uences as part of the deeply rooted practice of traditional medicine among Malay culture. 14,15Similarly, in Sabah, East Malaysia, 38% of TB contacts believed in the e ectiveness of traditional medications for TB treatment, while 56% were uncertain. 5In South Africa, 65.5% of TB contacts incorrectly believed in the curative properties of herbal medicine for TB, likely in uenced by the high regard and strong beliefs in traditional healers within certain communities. 7Conversely, a study in Vietnam reported that only 11% and 6% of individuals who adhered and did not adhere to follow-up, respectively, believed that traditional medications can cure TB. 8 If TB contacts are unsure about the bene ts of conventional treatment, they may be less motivated to adhere to contact screening activities, assuming that traditional healing methods might su ce or be equally e ective.Consequently, this can lead to delays in diagnosis, increased transmission rates and challenges in controlling TB within communities.

Implications for future research
As most participants cited forgetting their scheduled appointment as a factor for non-adherence, this potential barrier to completing their follow-up screening needs to be addressed.We suggest establishing innovative strategies such as scheduled earlier phone calls or written follow-up reminders several weeks before patients' subsequent TB contact screening appointment dates.Overall, there was acceptable knowledge of common TB symptoms but mixed response on how TB can be transmitted.e fact that DM was not recognised as a risk factor by almost half of the participants shows that more attention should be given to these patients to inform them of their risk.Future public health measures should be undertaken to ensure that the public is given clear and accurate information, especially on TB's airborne transmission, and identify areas for improvement in the information delivery at all levels.It is also important to emphasise that TB can potentially lead to death but is curable with proper treatment, not through unproven herbal or traditional treatments.
As this study mainly focused on patient-related factors in uencing follow-up adherence, future studies are suggested to analyse healthcare worker and service-related factors, e cacy of our current TB contact defaulter system, including ways to improve engagement with our local Health Inspectors.Psychosocial factors, such as the potential stigma of being a TB contact, should also be studied.A qualitative study design should be adopted to further explore the exact reasons for nonadherence and the factors a ecting TB knowledge.Future studies should also evaluate the incidence of TB among contacts during the rst year following exposure.is is relevant, as the incidence of new cases is the highest in the 1st year after exposure to a patient with TB. 7 How does this paper make a di erence in general practice?is study identi ed forgetfulness, knowledge gaps, and lack of awareness about comorbidities as factors hindering TB contact follow-up adherence.It highlighted the need for improved appointment reminder noti cations, patient education on TB transmission and treatment, awareness of DM as a risk factor, and need to improve engagement with Public Health services.

Strengths and limitations
To our knowledge, this study is the rst of its kind to be conducted in Sarawak, East Malaysia.e results provide general insights into the barriers to adherence and the TB knowledge of the local patient population.However, the study was conducted in a single setting, and the majority of the participants were Malays (as the local residents the clinic serves are mostly Malays).Owing to ethical and practical reasons, we were unable to evaluate the response of eligible TB contacts who were unwilling to participate and defaulters who did not turn up despite the clinic sta 's multiple attempts to contact them through phone calls.
Another potential limitation is that most participants provided a neutral response for the reasons for non-adherence and TB knowledge, perhaps due to nding some of the questions too sensitive to be answered.ere may also be social desirability bias among the participants, towards which they assumed a good response.Another major limitation is the sample size calculation based on a non-adherence rate of 68%.Our study noted a non-adherence rate of 19.1%, possibly a ecting the validity of the ndings.

Conclusion
Our study ndings show that there are improvements to be made in our reminder noti cations and 'call back' system for TB contacts to improve adherence, especially when there is such long screening interval.ere is also a need to disseminate accurate information about TB among the public, focusing on the modes of disease transmission.Future public health interventions (alongside health inspection) could include innovative reminder systems involving digital technology.

Figure 1 .
Figure 1.Flow chart of the study.Data collection period: August 2019 to January 2020.
• A structured and pre-tested questionnaire provided upon provision of consent Data entry and statistical analysis conducted using SPSS version 22 for Windows

Table 1 .
Association between the demographic characteristics and follow-up adherence.
*Social contacts: relatives of di erent households but who meet frequently **Institutional contacts: nursing/care home or prison facilities ***Other ethnicity: Indians, non-Malaysians and other races not otherwise speci ed
e highest rank is determined by the highest percentage of correct responses.

Table 4 .
TB knowledge and follow-up adherence.